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Altered Biomechanics and Spondylolysis
Terry R. Yochum DC, DACBR, Fellow ACCR
Alicia M. Yochum RN, DC, DACBR, RMSK
Mark E. Schweitzer, MD and Lawrence M. White MD
Department of Radiology
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania
Radiology 198:851
March 1996
Does Altered Biomechanics Cause Bone Marrow Edema?
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What is Bone Marrow Edema? • Inflammation in the
bone
• Injury to the trabeculae causing it to bleed
• Repetitive
• Impact
• Controversial Etiology
• Blood= Fluid
• Fluid= High signal Marrow (Fat)= BlackFluid = White
Materials and Methods • 12 Participants
• 6 Women 6 Men
• Age: 19-41 (Mean 30)
• All asymptomatic and without abnormal pronation
• MRI – baseline
• Bilateral foot, ankle, knee, and hip
• Scans utilizing a 1.5 Tesla magnet was done utilizing STIR imaging which suppresses fat signal and enhances water signal
• Insert
• 9/16” (1.4cm) longitudinal metatarsal arch pad inserted into the shoes of one foot of each volunteer
• Forces the participant into unilateral abnormal foot pronation
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Results
• An additional MRI scan was done after 2 weeks of forced abnormal foot pronation utilizing the insert
• 11 participants developed bright signal consistent with fluid/water indicating bone marrow edema (BME)
• 1 participant showed involvement on the contralateral foot
Location of BME
• Locations: Foot, Tibia, Femur
• Most were at metatarsal and phalangeal joints • 8 phalanges
• 4 metatarsals
• The most common was the first ray
• Some were more pronounced than others with 2 appearing similar to a stress fracture
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Initial
2 Weeks of
Abnormal
Pronation
Before After
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Results
Clinical
• Nearly all participants complained of pain or discomfort in the lower extremity during the study
• All volunteers were asymptomatic immediately after insert removal and at clinical follow up
• 1 day, 1 week, 1 month
Imaging Follow Up
• 3 volunteers were images a 3rd time (2 weeks after removal of the insert) to determine if the BME had resolved
• NO signal alteration was noted in the previous areas of BME in 2/3
• One participant demonstrated minimalpersistent edema that was more diffuse than when originally noted
ALTERED BIOMECHANICS AND BONE MARROW EDEMA – REVISITED
PARTICIPATING INVESTIGATORS
• Dr. Alicia M. Yochum – Principal Investigator
• Dr. Gary M. Guebert
• Dr. Jeff Thompson
• Dr. Terry R. Yochum
• Dr. Kim Christensen
• Dr. Reed B. Phillips
• Dr. Norman W. Kettner
• Dr. Mark Schweitzer (M.D.)
Logan College of Chiropractic Research Study, St. Louis, MO
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MATERIALS AND METHODS
• 22 total student participants • 17 treatment participants
• 5 control participants
• Inclusion Criteria • Normal BMI
• 20-30years old
• Exclusion Criteria • Pre-existing abnormal pronation of the
foot- Physical examination
• History of chronic low back or lower extremity pain in the last 6 months
• Use of opioid medications
• Runs more than 10 miles/week
• Preexisting conditions (metabolic, bone softening)
• Device that that would be incompatible with MRI (pacemaker)
Methods
• 17 participants placed in unilateral FORCED pronation utilizing a 9/16 inch insert in their right shoe
• Control Group: 5 Randomly Selected Participants- No insert
• Undergo all other aspects of study (VAS, Biomechanical Pictures, MRI’s)
• All students are instructed to go about their normal activities of daily life to include their normal exercise routine (running under 10mi/wk).
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Time line 6 Week Protocol • Initial MRI scan to make sure participants do not have preexisting BME
• 2 Weeks- MRI Scan after insert was in place for 2 weeks
• 4 Weeks- MRI Scan after 2 additional weeks of abnormal pronation with the insert• After this scan the insert was removed
• 6 Weeks- Follow up scan after 2 weeks without the pronation device to look for resolution of symptoms/edema
• At the time of each MRI scan, biomechanical pictures (overhead squat) were taken and a Numerical Rating Scale (NRS) was performed.
IMAGING STUDIES
• All participants were scanned with a 1.5 Tesla MRI magnet.
• STIR images obtained• Suppress all signal from fat so FLUID/EDEMA stands out White• Bone marrow/trabecular bone is
• The areas scanned: BILATERAL • Foot- Sagittal• Ankle- Sagittal • Knee- Coronal• Hip- Coronal• Sacroiliac Joint- Coronal• Lower lumbar spine- Sagittal
Black
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Image Interpretation
• Two Radiologists certified by the American Chiropractic Board of Radiology (ACBR)
• Dr. Gary Guebert and Dr. Jeff Thompson
• Blinded as to which students have been pronated and which ones have not.
Imaging RESULTS
• Talonavicular Joint- Initial Study NO BME
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MRI 2 MRI 3 MRI 4- Follow up
INITIAL
1
4
2
3
Posterior Lateral Talar Process (Stieda)
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MRI 3
L5 Right
Initial
MRI 2
MRI 4- Follow up
Lumbar Spine PedicleL4 Left
Initial MRI 2
NO EDEMA
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MRI 3 MRI 4- Follow Up
Pain Evaluation • Done before the study began and every 2 weeks (MRI)
• All scores were 0 initially = Patients had NO low back pain or lower extremity pain
• Oswestry: Done before study began and at the time of the 3rd MRI• Right before the insert was taken out
• 13 participants developed pain in their foot and knee
• NO hip pain
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Range: 6-58% Disability
Average: 27%
17% of participants = SEVERE disability!
1 participant was 3% away from CRIPPLED
Oswestry
All began at 0%
Data Analysis • Statistical Significance with p-value <0.05
• Bone Marrow Edema
• Fisher’s Exact (small sample size)
• Not statistically significant although those that developed BME were all in the treatment group
• Not random incidence
• p value- 0.59 and 0.77 (time point 2 and 3)
• Study is underpowered= not enough people
• Numerical Rating Scale
• Repeated ANOVA and T-Test
• Overall significance of pain over time: p-value <0.001
• Significance between time point 1 and 2 as well as 3 and 4.
• Significance between the treatment and control: p-value <0.05
• Significance in Knee pain in those who developed BME (p 0.01)
• Oswestry
• Pair-wise T-test
• Statistically significant difference in participants at the beginning of the study verses the end: p-value <0.001
• Statistically significant difference in control verses treatment
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What is pronation?...Normal part of the gait cycle
• Heel Strike: Supinated
• Midstance: Pronated
• Toe Off: Supinated
Abnormal Pronation
• Toe out- Pronounced heel strike in supination
• Excessive pronation in midstance
• Increased load on 1st toe at toe off
3 ARCHES… Heel Strike
Midstance
Toe
Off
Biomechanical faultsPossible Biomechanical effects of
ABNORMAL Pronation
• Dropped Arch (Calcaneal eversion)
• Toe out
• Medial deviation of the knee• Internal rotation and femur
• Genu valgus deformity
• Pelvic Unleveling
• Shoulder Unleveling
https://www.youtube.com/watch?v=DNn9KG9Tgx0
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Comparison
With Custom Orthotics- 1 Week LaterWithout Custom Orthotics
What did we see in our study?...Overhead squat Analysis
Most Common
1. Toe Out
2. Arch Drop (calcaneal eversion)
3. Knee Deviation (Medial/Lateral)
4. Forward Arms
5. Forward Lean
Uncommon • Forward Head
• Low Back Arch/Rounding
• Weight Shift
• Heels Up
NOT FOUND
PRE-EXISTING FUNCTIONAL BIOMECHANICAL
FAULTS!
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TOE OUT
Dropped arch (calcaneal Eversion)
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Knee Deviation • More commonly encountered on the left
Medial Lateral
Forward Arms/Lean
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What Causes Disc Degeneration?…….
Excessive mechanical loading!
• Causes a disc to degenerate by disrupting its structure and precipitating a cascade of nonreversible cell-mediated responses leading to further disruption. SPINE 2006
Sir Kirkaldy Willis MD
3 Stages of Degeneration
• Dysfunction
• Instability
• Stabilization
PRE-EXISTING FUNCTIONAL BIOMECHANICAL FAULTS!
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Calcaneal Inclination angle
• Normal: 20-30
Hallux Valgus
“Bunion”
Normal: 5-10 Case Courtesy of Logan University
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Knee Deviation
VARUS VALGUS
Hip OA
Case Courtesy of Logan University
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• _________=Altered Mechanics
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STRESS FRACTURES
Fatigue Fracture
• Normal bone that fails under an
abnormal load
Insufficiency Fracture
• Abnormal bone that fails under a
normal load
Imaging Signs of Stress Fractures
• Solid Periosteal new bone formation (Plain Films)
• Transverse opaque bands when seen “enface” (Plain Films)
• Fracture line seldom seen on plain films but best seen on CT
• Positive bone scan (Planar)
• Bone marrow edema on MRI
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INCIDENCE OF SPONDYLOLYSIS AND/OR SPONDYLOLISTHESIS
• CAUCASIAN: 5-7%
• AFRICAN AMERICANS: 2%
• ALASKAN ESKIMOS: 40%
• HIGHLY MOTIVATED ATHLETES PERFORMING HYPEREXTENSION: 15%
• GYMNASTS, DIVERS, POLE VAULTERS
• POWER WEIGHT LIFTERS: 40-50%
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• Tilt up view• 15-25 o cephalic tube
tilt
• CR half way between umbilicus & pubic ramus (1.5” below ASIS)
• AP Lumbar Spine• No tube tilt
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•Tilt up view L/S Jt.
No tube tilt Tube tilt
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Physical examination revealed painful hyperextension with some relief during flexion.
His pain was localized to the L4 segment
The patient exhibited a positive Stork test
Stork test
Single leg hyperextension
Plain film radiographs,
planar bone scan and two MRI
scans (three months apart)
were read as normal.
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Planar Bone Scan –Negative
• T2 Weighted Sagittal MRI
• Normal
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- Bone Marrow Edema
in the Left Pars
Parasagittal T2-weighted MRI Scan
- Bone Marrow Edema
in the Right Pars
Parasagittal T2-weighted MRI Scan
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Axial T1-weighted MRI L4
SPECT ScanSingle Photon Emission Computed Tomography
Coronal
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Parasagittal
SPECT ScanSingle Photon Emission Computed Tomography
No more SPECT bone scans
MRI with STIR
(short tau inversion recovery)
Fat suppression technique or
Fluid sensitive imaging
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Boston Brace International (508) 588-6060
www.bostonoverlapbrace.com
EL RASSI, ET ALLUMBAR SPONDYLOLYSIS IN PEDIATRIC AND ADOLESCENT SOCCER PLAYERSAMERICAN JOURNAL OF SPORTS MEDICINE, 33.1688-1693, 2005
•According to Rassi and colleagues, bracing itself, does not determine
successful results, whereas physical activity restriction has a higher
influence on clinical outcomes. The combination of both physical
activity restriction and lumbar bracing – would have a higher impact
when the clinical outcome is compared to the use of either alone.
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STEINER AND MICHELITREATMENT OF SYMPTOMATIC SPONDYLOLYSIS AND SPONDYLOLISTHESIS WITH MODIFIED BOSTON BRACESPINE:10:937-943, 1985
• According to Steiner and Micheli, clinical outcomes of patients undergoing
conservative treatment, along with spinal bracing found that patients
wearing the thoracolumbar orthosis obtained a higher functional outcome
(100% excellent results), compared to those not wearing the braces (68%
excellent results). Caution must be taken when attributing this increase
function to the use of the thoracolumbar orthoses alone. Patients needing
the brace were also patients needing a longer period of physical activity
restriction.
• The conclusion is that the reduction in physical activity, rest and the
thoracolumbar Boston Overlap Brace will yield the most positive clinical
results.